Other Cognitive-Behavioural Therapies for Borderline Personality Disorder

Cognitive-Behavioural Therapy (CBT) is best known for the relatively large body of outcome evidence supporting its application in the treatment of depressive and anxiety disorders. Comprehensive CBT approaches for personality disorder are typically modified, in that they are of long-term duration, offer an intensive frequency of patient-therapist contact, and incorporate technical elements from other treatment models. Please refer to the Schema-Focused Therapy (SFT) and Dialectical Behaviour Therapy (DBT) pages for an overview of these approaches. Promising results are also emerging regarding other CBT treatment packages for BPD, including short-term modules designed as adjuncts to standard care.

Cognitive Therapy

Cognitive therapy was compared against Rogerian client-centred therapy in a randomized controlled trial (RCT) of 65 patients with BPD. Both treatments were offered at the same intensity and duration of one year. The primary outcome criteria consisted of an independent evaluation of global functioning along with the patient’s level of hopelessness. There was no significant difference between the treatments on these criteria at the end of therapy, although patients in the cognitive therapy condition had significantly higher global functioning scores one year following termination. Patients who received cognitive therapy also stayed in treatment longer and experienced some improvements earlier than those who received client-centred therapy.

CBT plus Treatment-as-Usual

The addition of CBT to standard treatment was examined in a community-based RCT of 106 patients with BPD. The sample included patients with comorbid Axis I and substance use disorders. Patients were randomized into either CBT plus treatment-as-usual (TAU), or TAU alone. Up to 30 sessions of CBT were offered to patients in the CBT plus TAU condition over a one-year period. On average, these patients attended 16 sessions of CBT. Both groups showed sustained improvement at two-year follow-up; there were no significant between-group differences in psychiatric symptoms, social and interpersonal functioning, and quality of life. However, patients in the CBT plus TAU group did experience a significantly greater reduction in mean number of suicide acts, as well as in levels of distress, dysfunctional thinking, and state anxiety than patients without CBT. This finding is promising in that these improvements were noted even though patients’ attendance at CBT sessions was suboptimal. Interventions that address such attendance problems – recognized as a treatment-engagement issue – might conceivably contribute to greater therapeutic progress when CBT is added to treatment-as-usual.

An even briefer version of CBT added to TAU was compared with TAU alone in a small RCT. Patients with BPD (N = 30) were randomized to receive either TAU or six sessions of Manual Assisted Cognitive Therapy (MACT) along with TAU. MACT incorporates elements of DBT, CBT, and bibliotherapy. Those receiving MACT plus TAU had significantly fewer and less-severe self-harm acts at six-month follow up compared to patients in TAU alone. MACT sessions were well-attended, in contrast to an earlier study of MACT in which there was a high dropout rate. In that study, which had a larger sample, 38% of patients in the MACT condition did not attend the sessions, and no significant difference was found between MACT and TAU.

CBT and Psychoeducation

A program called Systems Training for Emotional Predictability and Problem Solving (STEPPS) was developed to supplement ongoing care for BPD with a 20-week course of CBT and psychoeducation. STEPPS involves psychoeducation for the patient’s family members and other health care providers, so that the patient’s support network can remain appropriately engaged and responsive. Patients also attend two-hour seminars each week regarding CBT and self-management skills. STEPPS is intended as an adjunct to the patient’s regular treatment. Patients with BPD (N = 124) were randomized to receive STEPPS plus TAU or simply TAU alone. There were no significant differences in overall crisis-service utilization, suicide attempts, and self-harm. However, patients who received STEPPS along with their regular care showed greater improvement in depression, negative affects and disturbed cognitions, impulsivity, and global and interpersonal functioning. The benefit of adding of STEPPS to standard care is thus encouraging, given its relatively brief duration and its effect on affective symptoms, an area in which DBT has been less successful.